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Abstract

This article discusses the connection between the Theory of Integral Nursing and the use of complementary and alternative medicine to rehabilitation nursing. Complementary and alternative health practices refers to methods, practices, and modalities that are outside of the realm of biomedicine. Some of the types of treatments and practices that are considered to be alternative include folk medicine, herbal medicine, homeopathy, faith healing, massage, energy healing, acupuncture and acupressure, supplements, aromatherapy, and music therapy. The Theory of Integral Nursing is explained in some detail. Components of self-care, nursing-based complementary and alternative medicine practices, and supplement alternatives for pain and antidepressant medications used in the rehabilitation setting are also reviewed.

Introduction

This article explores the connection between the Theory of Integral Nursing and the use of complementary and alternative medicine (CAM) (Johnson, Ward, Knutson, & Sendelbach, 2012), defined as practices and therapeutic modalities that are outside of the realm of biomedicine. These include the use of folk medicine, herbal medicine, homeopathy, faith healing, massage, energy healing, acupuncture and acupressure, supplements, naturopathy, aromatherapy, and music therapy. In the context of nursing practice, a more applicable term to be considered is complementary and alternative health practices. These health practices provide additional resources for rehabilitation nurses that can enhance conventional rehabilitation nursing care. Consistent with the Theory of Integral Nursing, the utilization of alternative practices, which have a holistic orientation, contribute to the wholeness of the individual nurse or patient, relate to the four perspectives of experience and reality, and assist rehabilitation nurses in their mission to be health advocates and coaches.

Significance of CAM in Rehabilitation Nursing

Studies specific to the use of complementary and alternative health practices for rehabilitation patients are limited, although Wainapel and colleagues investigated this in their 1998 study in which 29.1% of the study sample of rehabilitation patients used at least one form of CAM as part of their rehabilitation therapy. At the institutional level, the Commission on Accreditation of Rehabilitation Facilities (CARF), an independent, nonprofit agency which provides accreditation to a variety of rehabilitation and health services, added wellness and integrative health standards to the accreditation manual. In 2012 the inclusion of these standards was expanded to the brain injury rehabilitation section (Nathenson, Nathenson, & Divito, 2014). This demonstrates the importance of CAM and other integrative, wellness related practices for nurses in the rehabilitation setting.

The use, significance, and efficacy of CAM have been widely investigated in both the United States and internationally. The National Institutes of Health has established a National Center for Complementary and Alternative Medicine (NCCAM), an institutional branch specific to the funding and oversight of scientific research on CAM. Scientific research on CAM practices helps to ensure that the complementary approaches used by rehabilitation nurses are evidence-based and better understood by health practitioners. The significance of CAM in all branches of nursing is evidenced by the recent studies that indicate 38% of adults in the U.S. use some form of complementary practice (Harris, Cooper, Relton, & Thomas, 2012). With a rapidly growing aged population and increasing prevalence of chronic conditions, there is a greater expectation for availability of CAM and wellness services in healthcare (Senzon, 2010). Rehabilitation nurses must be poised and prepared to understand and provide these services. Nonpharmacologic and alternative practices are becoming more common in rehabilitation nursing. Past studies have suggested that CAM is widely used for pain in the rehab setting, and are perceived by patients as efficacious in treating their ailments (Wainapel et al., 1998). More recently, the use of CAM has been shown in multiple studies to be efficacious in neurobe-havioral rehabilitation for improvements in self-efficacy and behavioral manifestations. These functional improvements were found to enhance the sustainability of community reintegration efforts (McMillan, 2013).

Theoretical Basis for CAM Use in Rehabilitation Nursing

In light of the significance of CAM to patients and rehabilitation settings, integration of such practices is warranted. The Theory of Integral Nursing provides a theoretical framework for recommending the integration of CAM to the rehabilitation setting. The theory highlights the context of rehabilitation nursing; and evolved from holistic nursing concepts that are critical to patient-centered care. Holistic nursing encompasses any form of nursing practice that takes the whole person into account, including mind, body, and spirit (Klebanoff & Hess, 2013). A major construct in the Theory of Integral Nursing is the bio-psycho-social-spiritual framework. This framework mirrors the health philosophies of all forms of CAM due to their whole person approach; in contrast to the more pathological and reductionist orientation of biomedicine. The theory also includes contextual factors of environment and social interaction into the wholeness, or totality of the person (Dossey, 2013). The Theory of Integral Nursing includes a paradigm of experience and reality, represented by four quadrants: the individual interior, the individual exterior, the collective interior, and the collective exterior (Dossey, 2008). These quadrants all have a direct or indirect link to the holistic health philosophy the physiological efficacy, and the emotional and spiritual impact of CAM. In the first quadrant, the “individual interior,” which is a conceptualization of the self; is at the center of a subjective view of consciousness including personal beliefs, feelings, maturity, communications skills, and ultimately self-care. CAM modalities taking a whole person, bio-psycho-spiritual approach can help facilitate a nurse’s deeply personal but also patient-directed orientations of care provision. In other words, practices such as mediation, prayer, and visualization can impact a nurse’s spiritual maturity and emotionally stability. From this point, he or she can provide better care for the patient, even helping the patient to facilitate his or her own spiritual practice. The second quadrant the “individual exterior,” involves the behavioral and biological aspects of the self, alluding to skill development in the areas of physical health, nutrition, and brain development. Multiple forms of CAM directly influence physiology and cognitive function. The practice of acupuncture, tai chi, herbology and supplements, yoga, and chiropractic medicine can all improve both the nurse and patient’s vitality, balance, and ability to maintain good nutritional health. The third quadrant of experience and reality the “collective interior” is related to cultural or shared worldviews. This applies to CAM in that CAM is representative of a health philosophy that encompasses mind, body and spirit; differing starkly from the biomedical or pharmacological approach. It is thus imperative for rehabilitation nurses to understand the transdisciplinary nature of integrative medicine, in which both CAM and biomedicine can be used in conjunction with each other. This awareness of different worldviews in relation to health can also better prepare the rehab nurse to engage with other health practitioners, both conventional and alternative, to provide the best possible outcome for the patient. In this way, the nurse can provide a key role in bridging the gap between health modalities, patients, and practitioners. Finally, the “collective exterior” quadrant, an intersubjective reality; refers to larger systems and structures. This has great bearing on CAM integration, because it acknowledges the organizational systems, educational systems, and regulatory structures in medicine. For example, insurance policies play a part in what modalities can be offered by nurses and other health practitioners, and also may restrict healing options for rehabilitation patients. Regulation of CAM and institution-specific polities not only guides and controls but also constricts the level of integration of CAM into rehabilitation nursing practice. Nurses and administrators alike should be kept abreast of the significance of CAM to the patient population, so such policies can evolve and adapt to a changing health landscape.

The rehabilitation nurse’s understanding of the Theory of Integral Nursing and how these quadrants apply to CAM is important, because theory drives practice. The theory also provides the rehabilitation nurse with an understanding of how complementary and alternative health approaches can be effectively integrated into rehabilitation nursing practice. After all, rehabilitation nursing is about care of the whole person. This not only includes the mind body spirit connection but also a recognition of contextual factors that impact the rehabilitation patient such as vocation finances, family or caregiver support; as well as personal preferences and life goals (Geyh et al., 2011).

An underlying theme of the Theory of Integral Nursing is the assumption of the integration of the attributes of mind, body, and spirit; which provides a multifaceted approach to the metaparadigm of person. This recognizes internal aspects of self, inclusive of the spiritual, emotional, and psychological self—our inner voice so to speak. It also acknowledges each person’s relationship with the environmental and social realms of existence. Integral dialogs consist of exchanges of ideas across all clinical disciplines to expand practice for improving patient outcomes. To integrate CAM in conventional rehabilitation settings, worldviews and health philosophies must be understood on both sides; and the patient’s view and social context must be understood by all providers. The clinical application of CAM within this theoretical framework are salient as well; for example, the theory provides that a person’s emotional state has an impact on physical well-being, and as these concepts are multidirectional in relation to each other, it follows that spiritual well-being may have a healing effect on the emotional or physical health of the individual. In practice, this guides the nurse to assess the patient’s spiritual belief system and incorporate this into individualized patient care planning, which has been identified as a key goal in conventional medicine and healthcare (Reuben & Tinetti, 2012).

The Concept of Self-Care

As outlined in the first quadrant of the integral model, the individual interior; self-care practices can be described with the bio-psycho-social-spiritual framework. In the application of this framework, self-care activities are enhanced with CAM use. Self-care activities overlap and integrate all of the domains of self. Self-care activities for physical well-being include whole foods nutrition and exercise. When exercise is performed with mindfulness and intention the attribute of mind becomes engaged. For example, an activity such as yoga simultaneously engages the physical, psycho-emotional, and spiritual aspects of self; resulting in the multidimensional integration of self (Wright et al., 2012). In the practice of integral nursing the nurse engages in self-care practices; such as personal reflection and evaluation, as well as a method to explore the principles of a higher self. This results in self-awareness and the aspect of knowing. There are four aspects of knowing which have been derived from Carper’s (1978) original work. These include the use of empirical, personal, aesthetic, and ethical patterns of knowing. Empirical knowing is the assimilation of factual information, personal knowing is self-knowledge and an emotional ability to have insights and relate to others. Ethical knowledge is related to moral values and an ethical framework for decision making. Aesthetic knowing, as more recently described by Archibald (2012) comprises what has traditionally been called the art of nursing practice and adds the element of holistic awareness. This expanded view is more consistent with Dossey’s perspective, as it provides for a more enhanced understanding of the nurse-patient experience. In other words, it provides for a heightened awareness of the current state or situation, with the nurse being consciously aware and fully present in the here and now within the context of a healing environment (Clancy, 2013). The concept of unknowing is actually more central and significant in the Theory of Integral Nursing. It is the state of unknowing that allows the nurse, when fully present, to use his or her intuition to discover new insights to solve problems and improve outcomes. The process of unknowing is a cosmic link to the divine, which brings in the aspect of spirituality into the integral nursing process (Dossey, 2013).

Holism and the Bio-Psycho-Social Model

An aspect of the Theory of Integral Nursing that has implications for CAM integration is the bio-psycho-social model, first proposed by Drs. George Engel and John Romano at the University Rochester in the 1970’s. The model was developed to provide a more comprehensive systems approach to compliment the traditional biomedical models of medicine that focused on pathophysiology (Suls, Luger, & Martin, 2011). This model has application in wellness coaching and patient education in all areas of nursing. For example, in providing education with a patient who had a stroke, a common teaching point is the importance of stress management. In this example the framework helps to illustrate how emotional stress can have an impact on physical health and well-being. This guides the nurse in explaining how stress management may help prevent future occurrence of stroke (Everson-Rose et al., 2014).

The bio-psycho-social model also relates to the metaparadigms in the Theory of Integral Nursing. A metaparadigm provides a global perspective on a profession, in a sense it is a way to define the profession as a whole, demonstrating how it is distinct and unique from other professions. In nursing, there are four concepts that are considered as the metaparadigms of the profession: the nurse, patient, health, and environment (Butts, 2010). The meaning of each of the four metaparadigms is dynamic and each concept has a specific meaning which is dependent on the specific nursing theory. In other words the definition of each concept is context driven.

The concept of nurse, as described by the Theory of Integral Nursing, considers the nurse as a component of the therapeutic environment. This includes the concept of therapeutic use of self. This acknowledges that it is therapeutic for a nurse just to be with a patient when the nurse is mindful of his or her presence and mentally extends that sense of presence to the patient. The nurse enhances the therapeutic environment by practicing compassion and empathy (Crawford, Brown, Kvangarsnes, & Gilbert, 2014). This view of the metaparadigm of nurse builds on the concept definition found in Peplau’s Theory of Interpersonal Relations; where nursing is described as a therapeutic interpersonal process between the nurse and patient. There is a synergy between the nurse and the patient that facilitates growth in both parties (Schout, De Jong, & Zeelen, 2010).

The holistic concept of patient builds on Rogers’ Theory of Unitary Human Beings, where the concept of person (patient) is seen as being one with the universe, and is an energetic being manifested as frequencies or energy waves. The human energy field and the universal energy field are not dichotomous, rather they are constantly interacting. In this context, illness is seen as an imbalance in the human energy field (Monzillo & Gronowicz, 2011). In addition, patients can experience a loss of dignity in the patient role; this loss of dignity can result from a patient’s perception of indifference and condescension on the part of the nurse. The nurse can facilitate the preservation of the patient’s dignity by practicing self awareness of verbal and non-verbal communication, as well as engaging the patient’s participation in care through active listening and acknowledging the patient’s input (Baillie & Gallagher, 2012).

In the Theory of Integral Nursing, health is described in terms of wellness, which is a self-directed quest for optimal well-being along a multidimensional continuum of mind, body, and spirit (Strout, 2012). The conventional concept of health, on the other hand is dichotomous. A person is either seen as being in a state of health or state of illness. For example, persons with disabilities may be described as having an alteration in health due to limitations in physical functioning (Bickenbach, 2013). In the wellness paradigm a person with a mobility impairment may have enhanced self-efficacy from gaining mastery over the impairment (Baumann & Dang, 2012). In addition, they may have better than average BMI, cholesterol values, or physical endurance.

The concept of environment in the theory is all inclusive, encompassing physical surroundings as well as people. There is a synergy between the people in the environment and the physical nature of the environment. A physical environment that has calming or healing colors, where there is an absence of noxious sounds, and a presence of soft ambient sounds is conducive to healing for the patient and clinicians that are interacting within that environment. Call light noises, overhead pages and sounds from medical equipment are distracting and detract from the healing features desired in a therapeutic environment. It has been noted in studies that hourly rounding by nurses can reduce call lights, thus supporting a more therapeutic environment (France, Byers, Kearney, & Myatt, 2011). Taken together, the metaparadigms within the Theory of Integral Nursing as manifested in the concepts of nurse, patient, health, and environment, are all uniquely addressed by various CAM practices within rehabilitation nursing.

Nursing-Based CAM Practices

Many forms of CAM have roots within nursing practice. Energetic healing through touch and laying of hands are age old complementary practices that have been reintroduced by nursing innovators and have become legitimate nursing practices (Hart, 2012). There are different forms of energetic touch practices used by nurses including therapeutic touch, healing touch, and comfort touch. All of the techniques are based on interaction of the human energy fields between the nurse and patient with the purpose of removing blockages in the energy field to promote healing. Energetic touch therapies have been a nursing practice for more than thirty years. One of the earliest programs was developed in the 1970’s by Dr. Dolores Krieger, PhD, RN and Dora Kunz. Therapeutic Touch International Association provides for two levels of credentialing, the Qualified Therapeutic Touch Practitioner (QTTP) and the Therapeutic Touch Teacher (QTTT) (Therapeutic Touch International Association, n.d.). Therapeutic touch practitioners typically work in the human energy field as it extends a few inches from the body. The practitioner uses gentle strokes to rebalance energy and restore energetic dynamics by removing energy blockages (Krieger, 1993). Support for the mainstreaming of therapeutic touch is evidenced by the inclusion of the nursing diagnosis of Disturbed Energy Field (00050) in The North American Nursing Diagnosis Association (NANDA) Definitions and Classifications since 2004. This diagnosis is defined as an imbalance in the human energy field (Herdman, 2011).

Janet Mentgen, RN, BSN developed a method called Healing Touch in 1989. The program was supported by the American Holistic Nurses Association through a training program which began in 1993. Once Healing Touch International was chartered in 1996, training and certification responsibility was transferred to the new organization, Healing Touch International. The organization offers two credentials. At the practitioner level there is the Certified Healing Touch Practitioner (CHTP) credential and for teacher/trainers there is the Certified Healing Touch Instructor (CHTI) credential. Five levels of education and training are required for practitioner certification followed by a written examination. In Healing Touch the practitioner works with the human energetic field with the hands of the nurse (practitioner) being in the energy field of the patient (client) for certain techniques and in contact with the recipient’s body for other techniques. The basic maneuvers are comprised of an eight step process called the healing touch sequence. This sequence begins with asking for and receiving permission from the recipient to use healing touch to identify and treat health needs. The practitioner prepares through a self-centering technique and sets an intention to treat the recipient. The intention may be more generalized to improve wellness or it may be specific to work on a specific health issue requested by the recipient. The practitioner then performs a body scan by passing their hands palm down several inches above the recipient’s body with a focused awareness for body temperature, vibrational rate, magnetism or vibrational attraction, and density of energy flow. A magnetic pass may then be performed by holding the hands palm down a few inches from the recipients body and with a sweeping motion begin to come through the energy field brushing away areas of density and smoothing out the energy flow from head toward and slightly past the feet. After the assessment and magnetic pass the practitioner holds their hands palms down over any area of concern or where the recipient has been experiencing pain. This position is held until a change in density or vibrational rate, or a letting go is perceived. A reassessment scan is then completed and the practitioner grounds the recipient by holding their feet and gently calling out their name. The practitioner asks the recipient how the treatment went for them and remains available to discuss any feelings, sensations, or issues that surfaced for the recipient during the treatment. Additional techniques include magnetic clearing, chakra connection, trauma release technique, and different techniques to clear headaches (Hover-Kramer, Mentgen, & Scandrett-Hibdon, 1996). In a systematic review of the literature touch therapies were noted to achieve decreased pain response, as well as reductions in stress and anxiety. Of significance is that several studies indicated accelerated healing time and decreased use of medications (Anderson & Taylor, 2011). A more recent study demonstrated improvements in self-reported well-being and quality of life (So, Jiang, & Qin, 2013).

Acupuncture

While acupuncture is not a nursing modality it should be mentioned as a concomitant therapy that has efficacy in the rehabilitation setting the treatment of pain, depression, and in brain injury rehabilitation (Zhou et al., 2014). Acupuncture is widely used in the management of acute, chronic, and neuropathic pain. The most common form is basic needling, a technique that uses insertion of very fine needles which are inserted to a depth of 4–25 mm and left in place for a period of time. Generally one session includes work using 6–12 needles that are inserted at different acupoints at the same time. Some techniques include a microcurrent to the needle, or the current may be applied directly on the skin. Moxibustion is a technique that uses a heat source that is applied to the needle. This technique usually includes the use of a smoking herb (Asher et al., 2010).

Acupuncture is also used as a stand-alone or concomitant treatment for depression. The role of acupuncture is to identify and treat the underlying cause or imbalance that is contributing to the depression. In a large scale trial the underlying organ system imbalance was found to be liver or liver Qi (pronounced chee) stagnation followed by spleen deficiency syndrome. In addition to needle work, two thirds of the study participants were given lifestyle management counseling including nutrition and use of herbs, as well as relaxation and stress management techniques. (Mac-Pherson, Elliot, Hopton, Lansdown, & Richmond, 2013). In brain injury treatment needling and moxibustion are used to stimulate energy meridians in an effort to eliminate imbalances, and normalize nervous system response. In China, acupuncture is commonly used along with physical therapies in the rehabilitation setting (Zhou et al., 2014).

Supplements and Biologically Based Therapies

Supplements and other biologically based therapies are among the most widely used CAM therapies by both rehabilitation patients and the wider population (Frass et al., 2012). Supplements may play a unique role in navigating the use and consequences of pharmaceutical interventions in rehabilitation care. Rehabilitation nurses are often the first to observe and assess adverse drug reactions, which are common in many medications used the rehabilitation setting. When reporting adverse drug reactions to primary care physicians or attending physiatrist the nurse is in a position to suggest supplement alternatives for drugs which may not be well tolerated by the patient. Pain medications and antidepressants are both widely used in rehabilitation settings. With high prevalence of chronic pain and depression, and the need for long term care, risk of adverse drug reaction increases (Kouwenhoven, Kirkevold, Engedal, & Kim, 2011). When evaluating efficacy and safety of supplement use it is worth noting that the Centers for Disease Control (CDC) report that prescription drug use is responsible for some 36,000 deaths annually, more in fact than street drugs like heroin and cocaine combined (CDC, 2011). Conversely, the American Association of Poison Control Centers’ National Poison Data System reported that there were no deaths caused by nutritional supplements in 2010 (Bronstein et al., 2010). Pain seen in the rehabilitation setting includes acute pain, chronic pain, and neuropathic pain (Sadler, Wilson, & Colvin, 2013). Pain is linked to inflammation and so many patients are prescribed nonsteroidal anti-inflammatory drugs (NSAIDS) for their anti-inflammatory action to relieve pain. NSAID related mortality is estimated to be as high As 16,500 deaths per year due to gastrointestinal bleeding (Bluhm & Green, 2011). A botanical alternative to NSAID therapy is an Indian spice called Turmeric (Curcuma longa). This ancient remedy has been a part of Ayurvedic medicine for centuries used mostly for its anti-inflammatory activity. Many people may be familiar with turmeric as a spice and component of curry. The active ingredient curcumin, a mild COX-2 inhibitor, but does not possess COX-1 inhibition. As turmeric does not possess COX-1 inhibition activity there is no risk of gastropathology as exists with NSAIDS. Curcumin not only works through inhibition of inflammation by preventing the production of prostaglandins, it also promotes activation of inflammation-regulating genes through its effects on cell-signaling (Nieman, Cialdella-Kam, Knab, & Shanely, 2012). Another botanical that is used for its anti-inflammation effects is ginger (Zingiber officinale). Zingiber officinale possesses analgesic, anti-inflammatory, anti-nausea, and sugar-moderating effects in the body. Like curcumin it suppresses the synthesis in the body of the pro-inflammatory molecules known as prostaglandins. Emerging research shows how ginger extract can actually inhibit or deactivate genes in our body that encode the molecules involved in chronic inflammation (Hsiang et al., 2013). Recent studies also indicate the anti-inflammatory effects of Omega 3 fatty acids have equal or greater anti-inflammatory action than NSAIDS for neuropathic pain (Ko, Nowacki, Arse-neau, Eitel, & Hum, 2010).

Drugs like gabapentin and pregabalin are often used in the treatment of neuropathic pain. These drugs were originally approved for the treatment of seizures. These are very dangerous drugs because of the severity of side effects. For example, the FDA has reported that side effects of Neurontin (gabapentin) include thoughts about suicide or dying, new or worse depression, panic attacks, acting aggressive, being angry, or violent acting on dangerous impulses (Hesdorffer & Kanner, 2009). The supplement alternative to drugs like gabapentin and pre-gabalin is gamma-aminobutyric acid (GABA). GABA is the chief inhibitory neurotransmitter in the mammalian central nervous system. It plays a role in regulating neuronal excitability throughout the nervous system. GABA functions to turn down the nociceptive pain signal. Research data on the mode of action accumulated is providing evidence that GABA as well as adenosine-related mechanisms are involved in the pain amelioration in neuropathic pain conditions related to spinal cord injury (Bráaz et al., 2012).

Depression is commonly treated by pharmacologic products (Ramasubbu, 2011) which have adverse side effects that are not present in alternative approaches (Beuth, Van Leendert, Schneider, & Uhlenbruck, 2013). In addition to the positive effect of the no-cost mindfulness meditation practice (Coelho, Canter, & Ernst, 2013), several supplements appear to be helpful in the treatment of depression. A meta-analysis indicated that St. John’s Wort (Hypericum perforatum) had equal efficacy to anti-depressant medications. In Germany St. John’s Wort is prescribed more frequently than antidepressants (Dwyer, Whitten, & Hawrelak, 2011). The supplement S-adenosyl-methionine is a synthetic amino acid that was shown to reduce depression scores in 80% of randomized trials (Papakostas, Cassiello, & Iovieno, 2012). Omega 3 fatty acids, noted for their health effects on cholesterol were shown to decrease depression scores in 16 clinical trials (Nahas & Sheikh, 2011).

Research Applications

In the practice of holistic nursing it is important to utilize research in clinical practice. In order for nurses to incorporate holistic nursing theory and research into practice, it is essential to expand research efforts regarding alternative and complementary interventions and treatments. These research efforts are necessary to validate the safety and efficacy of alternative and complementary approaches. There is a series of questions that are relevant to the consideration of research when it comes to complementary and alternative interventions aimed at wellness, prevention, and treatment. The first is an examination of the physical sciences, for example, what is the biological and chemical basis of the intervention? Second, what is the physiological basis for action and intended outcome? Third, is the treatment or substance safe for humans? If there are positive findings of these questions, the next step is an ethical determination for human trials for qualitative or quantitative testing. Qualitative testing is relevant because holistic health inds value in the perception or subjective elements of well-being in addition to the quantitative and empirical evidence (Smith, 2012). For example, one of the techniques used by holistic nurses is therapeutic touch for pain control. To provide evidence-based care the question of the efficacy of this practice must be addressed. A recent study indicated that therapeutic touch was effective in treating patients with fibromyalgia. Fibromyalgia is an autoimmune disorder known for its significant neuropathic pain. In the study fibromyalgia patients not only had significant improvement in pain levels after a series of therapeutic touch treatments, they reported improved quality of life (Terhorst, Schneider, Kim, Goozdich, & Stilley, 2011). Aromatherapy is also a CAM modality that is worthy of continued research, and is increasingly used in various settings to reduce anxiety and promote more positive behaviors. The use of aromatherapy with patients with behavioral problems has been found by some studies to be beneficial (Fung, Tsang, & Chung, 2012), but results overall have been mixed, warranting further investigation (Fu, Moyle, & Cooke, 2013).

Conclusion

The aim of this article was to provide a theoretical framework and content for the integration of complementary and alternative medicine (CAM) practices in rehabilitation nursing. CAM use has become increasingly prevalent, with almost half of all adults in the United States using CAM, and research indicating use in similar pattern within the rehabilitation patient population. Theory is critical in the incorporation of new practice paradigms. In this article, The Theory of Integral Nursing was shown to provide a meaningful framework for the integration of CAM in rehabilitation nursing. The Theory of Integral Nursing, including the four quadrants of experience and reality, the bio-psycho-social approach, and the metaparadigms of nurse, patient, health, and environment all provide an impetus for careful consideration of CAM use in rehabilitation nursing. Nursing-based CAM practices, mindfulness, acupuncture, and biologically-based therapies were reviewed, which can be seamlessly integrated into rehabilitation nursing practice in addition to therapies such as aromatherapy. Further, it was demonstrated that CAM can be efficacious in the rehabilitation setting both as a treatment option in a patient-centered, wellness approach, as well as a key contributor to nurse well-being and therapeutic impact. CAM continues to be a research priority, guided by theory, and ultimately integrated into rehabilitation practice.

Disclosure

The authors declare no conflict of interest.

Key Practice Points

Complementary and Alternative Medicine (CAM) is used increasingly in the population of rehabilitation patients.

The Theory of Integral Nursing provides a framework to support the integration of complementary and alterna-tive medicine (CAM) in rehabilitation nursing.

Within the bio-psycho-social framework, CAM facilitates health in both nurse and patient.

Nurse-based practices such as healing touch, as well as meditation, acupuncture, supplements, and aromatherapy are among commonly used CAM practices in rehabilitation nursing.